A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is ["A","B","C","D"]
Explanation
A. Spontaneous bleeding after taking an anticoagulant is a secondary action that occurs due to the anticoagulant's effect on blood clotting, which is an undesired effect when it leads to excessive bleeding.
B. Dizziness after starting an antihypertensive is a common secondary action related to the lowering of blood pressure, which can lead to hypotension and resultant dizziness.
C. Drowsiness after taking an antihistamine is a well-known secondary action, especially with first-generation antihistamines, which can cause sedation as a side effect.
D. Diarrhea after taking an antibiotic is a secondary action that can occur due to disruption of the normal gut flora, leading to gastrointestinal upset. All these examples illustrate secondary effects of medications.
Correct Answer is B
Explanation
A. Performing a blood sugar analysis is important, but the immediate symptoms indicate hypoglycemia, and rapid treatment is necessary before confirming blood sugar levels.
B. Having the client drink a glass of orange juice provides a quick source of glucose to counteract hypoglycemia, which is the most appropriate initial response to address the client's symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an appropriate intervention for severe hypoglycemia but is not the initial step for a client who can still take oral carbohydrates.
D. Administering insulin would worsen the client's condition by lowering blood sugar levels further, which is not indicated in this scenario.